Provider Demographics
NPI: | 1477850592 |
---|---|
Name: | MAINEHEALTH |
Entity Type: | Organization |
Organization Name: | MAINEHEALTH |
Other - Org Name: | MAINE MEDICAL PARTNERS PEDIATRIC SPECIALTY CARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ASSOCIATE CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LUGENE |
Authorized Official - Middle Name: | ANTHONY |
Authorized Official - Last Name: | INZANA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 207-662-3538 |
Mailing Address - Street 1: | 22 BRAMHALL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04102-3134 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-662-6562 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 887 CONGRESS ST |
Practice Address - Street 2: | SUITE 320 |
Practice Address - City: | PORTLAND |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04102 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-662-5522 |
Practice Address - Fax: | 207-662-5526 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MAINEHEALTH |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2011-02-25 |
Last Update Date: | 2022-12-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
1041C0700X, 133V00000X, 170300000X, 207RG0100X, 207SG0201X, 2080P0006X, 2080P0205X, 2080P0208X, 2080P0210X, 2080P0214X, 363LF0000X, 363LP0200X | ||
ME | 37563 | 282N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
No | 170300000X | Other Service Providers | Genetic Counselor, MS | Group - Multi-Specialty | |
No | 207SG0201X | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | Group - Multi-Specialty |
No | 2080P0006X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental - Behavioral Pediatrics | Group - Multi-Specialty |
No | 2080P0205X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | Group - Multi-Specialty |
No | 2080P0208X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | Group - Multi-Specialty |
No | 2080P0210X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | Group - Multi-Specialty |
No | 2080P0214X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | Group - Multi-Specialty |
No | 282N00000X | Hospitals | General Acute Care Hospital | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 200009 | Medicare Oscar/Certification |